The nursing care for the medical device related pressure injury patient with a mucosal pressure injury due to an endotracheal tube: a case report.

BACKGROUND: Pressure injury (PI) due to medical devices is one of the most common PIs, especially in patients treated in intensive care. Medical device-related pressure injuries (MDRPIs), as part of their treatment, require extra care and prevention interventions than injuries caused by immobilization. Standardized nursing models are needed to care for PIs caused by medical devices on mucous membranes. PURPOSE: To provide information about the evaluation and care of the MDRPIs in the mucosal membrane due to the endotracheal tube (ET). CASE REPORT: A 35-year-old male with chronic obstructive pulmonary disease (COPD) and coronavirus disease has MDRPIs on the lower lip edge due to the ET on the fifteenth day after intubation. North American Nursing Diagnosis Association (NANDA) diagnoses were determined by systematically analyzing the data using the Gordon's Functional Health Patterns (GFHP) model in the patient. Nursing care was planned and applied in line with the determined NANDA diagnoses, Nursing Outcomes Classification (NOC) interventions, and using the recommendations of current PI guides for treatment of MDRPIs. CONCLUSION: This case report illustrates MDRPIs resulting from ET and provides information about the formation of MDRPIs and appropriate maintenance therapy. Future research is recommended to examine and evaluate the nursing care and outcome of MDRPIs in different mucosal membranes.

The risk of pressure ulcers in a proned COVID population.

The utilisation of prone positioning has been vital during the COVID-19 pandemic, however risks the development of anterior pressure ulcers. An observational study was performed to examine the prevalence of pressure ulcers in this population and define risk factors. Eighty-seven patients admitted to critical care were studied. Of 62 patients with >1 day in prone position, 55 (88.7%) developed anterior pressure ulcers, 91% of which were anterior. The most commonly affected site were the oral commisures (34.6%), related to endotracheal tube placement. Prone positioning (p < .001) and the number of days prone (OR 3.11, 95% CI 1.46-6.62, p = 0.003) were a significant risk factors in development of an anterior ulcer. Prone positioning is therefore a significant cause of anterior pressure ulcers in this population.

Characteristics of COVID-19 patients who developed pressure injuries: a scoping review.

OBJECTIVE: To describe the characteristics of patients with COVID-19 who developed pressure injuries (PIs), the characteristics of PIs experienced, and the incidence and prevalence of PIs among the patients with COVID-19. PIs are associated with increased morbidity, mortality and healthcare expense. PIs have been reported among patients who have contracted COVID-19. Understanding the characteristics of COVID-19 patients, and how PIs are prevented and managed, may inform care and optimise the outcomes for COVID-19-positive patients. METHOD: A scoping review was conducted. All study designs, including grey literature, published in the English language from December 2019 to March 2021, reporting on patients with COVID-19 and PIs, were included. RESULTS: In total, 27 publications (n=4820 patients) were included in the review. The reported incidence rate of PIs was 7.3-77.0%. The causative factors noted were: prone positioning (28.5%); medical devices (21.4%); and medical devices used during prone positioning (14.2%). The most common PI sites were the cheeks (18.7%). PIs occurred on average at 14.7 days post-acute care admission. Of the PIs where staging information was specified (67.7%), the most common was Stage 2/II (45.2%). PI risk may intensify on account of the intrinsic mechanism of COVID-19-associated intensive care treatment. CONCLUSION: PI prevention and management should be prioritised for patients with COVID-19, given the reported high prevalence of PIs and exacerbated risk arising from the use of prone position and medical devices. Further research is required to understand the association between COVID-19 and PIs, and to guide effective prevention and treatment approaches.

Pressure Injury Prevention in Patients in Prone Position With Acute Respiratory Distress Syndrome and COVID-19.

INTRODUCTION: In patients with acute respiratory distress syndrome, prone positioning improves oxygenation and reduces mortality. Pressure injuries occur frequently because of prolonged prone positioning in high-risk patients, and preventive measures are limited. This article describes 2 patients who developed minimal pressure injuries despite several prone positionings. Prevention strategies are also described. CLINICAL FINDINGS: A 64-year-old man and a 76-year-old woman were admitted to the hospital with respiratory insufficiency. Due to acute respiratory distress syndrome, both patients were intubated and received mechanical ventilation and prone positioning. DIAGNOSIS: Both patients had positive test results for SARS-CoV-2 and a diagnosis of acute respiratory distress syndrome. INTERVENTIONS: Patient 1 was in prone position for 137 hours during 9 rounds of prone positioning; patient 2, for 99 hours during 6 rounds of prone positioning. The standardized pressure injury prevention bundle for prone positioning consisted of skin care, nipple protection with a multilayer foam dressing, a 2-part prone positioning set, and micropositioning maneuvers. For both patients, 2-cm-thick mixed-porosity polyurethane foam was added between skin and positioning set in the thoracic and pelvic areas and a polyurethane foam cushion was added under the head. OUTCOMES: Patient 1 developed no pressure injuries. Patient 2 developed category 2 pressure injuries on the chin and above the right eye during deviations from the protocol. CONCLUSION: For both patients, the additional application of polyurethane foam was effective for preventing pressure injuries. These case reports support the addition of polyurethane foam to prevent pressure injuries in patients placed in the prone position.

Characteristics of Patients with Pressure Injuries in a COVID-19 Referral Hospital.

OBJECTIVE: This retrospective study aimed to describe the characteristics of patients treated at a COVID-19 referral hospital from March 2020 to June 2021 who experienced pressure injuries (PIs) either before or after admission. METHODS: The researchers collected and analyzed data on patients' demographic characteristics, symptoms, comorbidities, location and severity of PI, laboratory values, oxygen therapy, length of stay, and vasopressor use. RESULTS: During the study period, 1,070 patients were hospitalized for COVID-19 with varying degrees of severity, and 12 patients were diagnosed with PI. Eight (66.7%) of the patients with PI were men. The median age was 60 (range, 51-71) years, and half of the patients had obesity. Eleven of the patients with PI (91.4%) had at least one comorbid condition. The sacrum and gluteus were the two most commonly affected sites. Those with stage 3 PI had a substantially greater median d-dimer value (7,900 ng/mL) than patients with stage 2 PI (1,100 ng/mL). The average length of stay was 22 (range, 9.8-40.3) days. CONCLUSIONS: Health professionals should be aware of an increase in d-dimer in patients with COVID-19 and PI. Even though PIs in these patients might not result in mortality, an increase in morbidity can be avoided with the right care.

Incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic: A systematic review and meta-analysis.

AIM: To evaluate the incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic in a meta-analysis. METHODS: Related studies were obtained through electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) Chinese Scientific Journal (VIP) China Biomedical Literature service systems (CBM) and Wanfang Data (from inception to 27 November 2021). The pooled incidence and the 95% confidence interval of facial pressure injuries were calculated with Review Manager v5.4 software. RESULTS: Overall, 16 studies with 14 430 health-care professionals were included. Pooled results showed that the pooled incidence of facial pressure injury in health-care professionals was 58.8% (95% CI: 49.0%-68.7%; p < 0.01). The results of the subgroup analysis showed that the incidence of facial pressure injury in these staff was high, and predominantly stage I pressure injury, in the following cases: in health-care professionals who wore personal protective equipment for longer than 4 h, in those without any training experience, and on the nose. CONCLUSION: Administrators and researchers should pay attention to preventing facial pressure injury related to the wearing of personal protective equipment (PPE) by ensuring all health-care professionals receive training and by limiting prolonged periods of use.

Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation.

OBJECTIVE: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22h [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.

Influencing factors of medical device-related pressure ulcers in medical personnel during the COVID-19 pandemic: A systematic review and meta-analysis.

OBJECTIVE: To determine the influencing factors of medical device related pressure injury (MDRPU) in medical staff by meta-analysis. METHODS: A comprehensive literature search was conducted by PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, CBM, and WanFang Data (from inception to July 27, 2022). Two researchers independently performed literature screening, quality evaluation and data extraction, and meta-analysis was conducted with RevMan 5.4 and Stata12.0 software. RESULTS: Total of 11215 medical staff were included in 9 articles. Meta analysis showed that gender, occupation, sweating, wearing time, single working time, department of COVID-19, preventive measures, and level 3 PPE were the risk factors for MDRPU in medical staff (P < 0.05). CONCLUSION: The outbreak of COVID-19 led to the occurrence of MDRPU among medical staff, and the influencing factors should be focused on. The medical administrator can further improve and standardize the preventive measures of MDRPU according to the influencing factors. Medical staff should accurately identify high-risk factors in the clinical work process, implement intervention measures, and reduce the incidence of MDRPU.

EffEctiveness of Prophylactic fOam dressings in the prevention of saCral pressure injuries in at-risk hospitalised patients: the EEPOC trial.

BACKGROUND: Prophylactic dressings are increasingly used to prevent pressure injuries in hospitalised patients. However, evidence regarding the effectiveness of these dressings is still emerging. This trial aims to determine the clinical and cost-effectiveness of a prophylactic silicone foam border dressing in preventing sacral pressure injuries in medical-surgical patients. METHODS: This is a multicentre, pragmatic, parallel group, randomised controlled trial. A sample size of 1320 was calculated to have >90% power to detect a 5% difference in the primary outcome at an alpha of 0.05. Adult patients admitted to participating medical-surgical wards are screened for eligibility: ≥18 years, admitted to hospital within the previous 36 h, expected length of stay of ≥24 h, and assessed high risk for hospital-acquired pressure injury. Consenting participants are randomly allocated to either prophylactic silicone foam dressing intervention or usual care without any dressing as the control group via a web-based randomisation service independent of the trial. Patients are enrolled across three Australian hospitals. The primary outcome is the cumulative incidence of patients who develop a sacral pressure injury. Secondary outcomes include the time to sacral pressure injury, incidence of severity (stage) of sacral pressure injury, cost-effectiveness of dressings, and process evaluation. Participant outcomes are assessed daily for up to 14 days by blinded independent outcome assessors using de-identified, digitally modified sacral photographs. Those who develop a sacral pressure injury are followed for an additional 14 days to estimate costs of pressure injury treatment. Analysis of clinical outcomes will be based on intention-to-treat, per-protocol, and sensitivity analyses. DISCUSSION: This trial aims to provide definitive evidence on the effect prophylactic dressings have on the development of hospital-acquired sacral pressure injuries in medical-surgical patients. A parallel economic evaluation of pressure injury prevention and treatment will enable evidence-informed decisions and policy. The inclusion of a process evaluation will help to explain the contextual factors that may have a bearing on trial results including the acceptability of the dressings to patients and staff. The trial commenced 5 March 2020 and has been significantly delayed due to COVID-19. TRIAL REGISTRATION: ANZCTR ACTRN12619000763145. Prospectively registered on 22 May 2019.

Pressure Injury Management in Critically Ill Patients with COVID-19 in a Makeshift Hospital in Indonesia: A Report of Two Cases.

ABSTRACT: Patients who are critically ill with COVID-19 need ventilation support in the ICU. However, ICU patients are at higher risk of developing a pressure injury (PI). Unfortunately, PI prevention is not optimally implemented in Indonesia, especially in the makeshift hospitals created during the COVID-19 pandemic. Here, the authors report two cases of critically ill patients with COVID-19 who developed large sacral PIs during hospitalization in a makeshift hospital in Indonesia. The first patient developed a stage 3, 7 × 7-cm sacral PI on the 14th day of hospitalization. The second patient developed a stage 4, 12 × 8-cm sacral PI on the 16th day of hospitalization. Both patients had elevated d-dimer levels and used a noninvasive ventilator for 1 week. The wounds were treated with surgical debridement, silver hydrogel dressing, and hydrocolloid dressing and complemented with static air mattress overlay. The authors recommend that in situations where there is a shortage of healthcare workers, the government should provide pressure-redistribution devices and silicone foam dressings for all critically ill patients to prevent PI development and lighten the workload of healthcare workers.

Pressure Injury Risk Assessment and Prevention in Patients With COVID-19 in the Intensive Care Unit.

BACKGROUND: Patients critically ill with COVID-19 are at risk for hospital-acquired pressure injury, including device-related pressure injury. METHODS: Braden Scale predictive validity was compared between patients with and without COVID-19, and a logistic regression model was developed to identify risk factors for device-related pressure injury. RESULTS: A total of 1920 patients were included in the study sample, including 407 with COVID-19. Among the latter group, at least 1 hospital-acquired pressure injury developed in each of 120 patients (29%); of those, device-related pressure injury developed in 55 patients (46%). The Braden Scale score area under the receiver operating characteristic curve was 0.72 in patients without COVID-19 and 0.71 in patients with COVID-19, indicating fair to poor discrimination. CONCLUSIONS: Fragile skin and prone positioning during mechanical ventilatory support were risk factors for device-related pressure injury. Clinicians may consider incorporating factors not included in the Braden Scale (eg, oxygenation and perfusion) in routine risk assessment and should maintain vigilance in their efforts to protect patients with COVID-19 from device-related pressure injury.

Protective equipment-related pressure ulcers in healthcare workers during COVID-19 pandemic: A systematic review.

AIM: This systematic review was carried out to examine pressure ulcers in healthcare staff due to the use of protective equipment during COVID-19 pandemic and the precautions taken to prevent these injuries. METHOD: Relevant studies were retrospectively searched. Seven English keywords identified from MESH were used while searching. The search was carried out in five international databases by trying various combinations of these words during February 15-25, 2021. This systematic review was updated by rescanning databases on December 20, 2021 and a total of 611 studies were attained. RESULTS: 17 studies which met the study inclusion criteria, which were conducted mostly through online survey method in different study designs and which included a total of 24,889 healthcare professionals were examined. The incidence of PPE-related pressure ulcers was found to be between 30% and 92.8%. Grade I pressure ulcers were the most common (44.1%-82%). The incidence of skin problems except PPE-related pressure ulcers such as itching, redness and dry skin was found to be between 42.8-88.1%. Risk factors that frequently played a role in the development of PPE-related pressure ulcers and other skin problems were longer use of PPE and sweating. PPE-related pressure ulcers and other skin problems were more frequent over the nose (nasal bone/nasal bridge), ears, forehead and cheeks. PPE-related itching, redness and dry skin mostly occurred. Several dressing applications were found to be effective in the prevention of PPE-related pressure ulcers and other skin problems that might develop especially on the facial region. CONCLUSION: PPE-related pressure ulcers and other skin problems were found to be higher among healthcare professionals. Data regarding the sealing of dressing applications against viral transmission in the prevention of PPE-related pressure ulcers and other skin problems are limited. It is estimated that future studies will be performed to prevent device-related pressure ulcers in healthcare workers. It is suggested that there is a need to conduct studies with larger samples where expert researchers make observations for pressure ulcers in order to determine the prevalence and incidence of PPE-related pressure ulcers.

Post-COVID Complications after Pressure Ulcer Surgery in Patients with Spinal Cord Injury Associate with Creatine Kinase Upregulation in Adipose Tissue.

The risk of complications following surgical procedures is significantly increased in patients with SARS-CoV-2 infection. However, the mechanisms underlying these correlations are not fully known. Spinal cord injury (SCI) patients who underwent reconstructive surgery for pressure ulcers (PUs) before and during the COVID-19 pandemic were included in this study. The patient's postoperative progression was registered, and the subcutaneous white adipose tissue (s-WAT) surrounding the ulcers was analyzed by proteomic and immunohistochemical assays to identify the molecular/cellular signatures of impaired recovery. Patients with SCI and a COVID-19-positive diagnosis showed worse recovery and severe postoperative complications, requiring reintervention. Several proteins were upregulated in the adipose tissue of these patients. Among them, CKMT2 and CKM stood out, and CKM increased for up to 60 days after the COVID-19 diagnosis. Moreover, CKMT2 and CKM were largely found in MGCs within the s-WAT of COVID patients. Some of these proteins presented post-translational modifications and were targeted by autoantibodies in the serum of COVID patients. Overall, our results indicate that CKMT2, CKM, and the presence of MGCs in the adipose tissue surrounding PUs in post-COVID patients could be predictive biomarkers of postsurgical complications. These results suggest that the inflammatory response in adipose tissue may underlie the defective repair seen after surgery.

Factors affecting the incidence and prevalence of pressure ulcers in COVID-19 patients admitted with a Braden scale below 14 in the intensive care unit: Retrospective cohort study.

The pandemic of coronavirus (COVID-19) has significantly increased the admission of patients with extensive complications, especially for respiratory support, to intensive care units (ICUs) worldwide. These patients also suffer from pressure ulcers (PUs) as another complication that occurs due to increased length of hospitalisation and acute conditions of patients. Therefore, this study aimed to evaluate the incidence and prevalence of PU and the factors affecting it in COVID-19 patients admitted to ICUs. This cohort retrospective study used registry data in Imam Reza Hospital located in west of Iran. Four hundred and forty-five COVID-19 patients older than 20 years hospitalised in corona ICUs from 20 March 2020 to 30 December 2020, with a Braden score of less than 14 were included in the study. To investigate the relationship between variables in rate prevalence, univariate logistic regression analysis was used to calculate odds ratio, and for incidence rate in estimating PU risk generated in ICUs, hazard ratio was calculated using cox regression. One hundred and eighty-three (41.12%) patients were male. The mean age of patients was 63 (SD = ±9.78) years. A total of 1152 cases of PU were generated, with the highest prevalence of PU with 234 cases in the sacrum. One hundred and seventy-six (55.87%) patients underwent non-invasive ventilation ulcers. The prevalence of PU was 79.7%. The highest prevalence was found in people over 80 years with 90.67%. The incidence ratio was 46.74%. The highest number of new cases was seen in diabetic patients with 60.96%. First-degree ulcers were the most common degree of ulceration in 252 (55.38%) patients. Incidence and prevalence excluding first-degree wounds were 24.04% and 49.66%, respectively. Age, Braden score, BMI, comorbidity, diabetes mellitus, stool incontinence, Glasgow coma scale, vasopressor, and length of hospital stay were significantly associated with PU (P < .05). The incidence and prevalence of PU in patients were high in this study. The length of hospitalisation and Braden score were the most important factors in the development of PU. The widespread prevalence of COVID-19 and the relatively long stay of patients in the ICU created unfavourable conditions for patients and the treatment system, therefore, it emphasised the use of appropriate measures to prevent PU to avoid double costs and longer stays.

Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing pressure ulcers, falling, and social vulnerability: An observational study.

AIM: To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators. BACKGROUND: Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary. METHOD: This was an observational descriptive study carried out from February to November 2020 with a sample of 1131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave. RESULTS: A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p < 0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit. CONCLUSIONS: The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions. IMPLICATIONS FOR NURSING MANAGEMENT: Support from nursing managers at health care facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.

Modeling Patient Risk for Hospital-Acquired Pressure Injuries During COVID-19: A Retrospective Study.

BACKGROUND: COVID-19 negatively impacts many organ systems including the skin. One of the most significant skin-associated adverse events related to hospitalization are pressure injuries. PURPOSE: The aim of this study was to determine 8 risk factors that would place hospitalized patients at a higher risk for hospital-acquired pressure injuries (HAPIs) during the COVID-19 pandemic. METHODS: A retrospective, descriptive analysis was conducted in an urban academic health science center located in the southeastern United States. RESULTS: There were 247 of 23 093 patients who had pressure injuries and 1053 patients who had a positive COVID-19 diagnosis. Based on the generalized estimating equation model, diagnosis of COVID-19, age, male gender, risk of mortality, severity of illness, and length of stay are statistically significant factors associated with the development of HAPIs. CONCLUSIONS: Further study should explore pathology of COVID-19 skin changes and what interventions are effective against HAPIs in the COVID-19 population taking into consideration current treatments.

The aetiology of medical device-related pressure ulcers and how to prevent them.

This article provides an introduction to the aetiology of medical device-related pressure ulcers (MDRPUs), describes the vicious cycle that leads to these injuries and highlights bioengineering methodologies and findings that connect the aetiology to the clinical practice of preventing MDRPUs. Specifically, the vicious cycle of MDRPUs is triggered by the sustained tissue deformations induced by a skin-contacting device. The primary, deformation-inflicted cell damage leads to a secondary inflammatory-oedema-related damage and then to tertiary ischaemic damage. Each of these three factors contributes to cumulative cell death and tissue damage under and near the applied device. The damage therefore develops in an escalated manner, as a result of the added contributions of the above three factors. This phenomenon is exemplified through two common clinical scenarios. First, through the use of continuous positive airway pressure (CPAP) masks, which are being applied extensively in the current COVID-19 pandemic, and, second, through the use of doughnut-shaped head positioners, which are applied to surgical patients and sometimes to bedridden individuals who receive intensive care in a supine position. These two medical devices cause intense, localised mechanical loads in the facial skin and underlying tissues (CPAP mask) and at the occipital scalp (doughnut-shaped positioner), where the soft tissues cannot swell in response to the inflammatory oedema as, in both cases, the tissues are sandwiched between the device and the skull. Accordingly, the two device types result in characteristic MDRPUs that are avoidable through appropriate prophylactic interventions, that is, preventive dressings under the CPAP mask and replacement of the doughnut device by a soft, shape-conforming support aid to alleviate and disperse the localised soft tissue deformations. Hence, understanding the aetiology of MDRPUs targets and focuses effective clinical interventions.

Full-Thickness Facial Pressure Injury and Buried Dentition from Prone Positioning in a Patient with COVID-19.

ABSTRACT: Prone positioning is recognized for its efficacy in the treatment of acute respiratory distress syndrome related to COVID-19. Here the authors present a case of a facial pressure injury and buried dentition that occurred as a result of prolonged prone positioning in a patient who was COVID-19 positive. The patient was treated with primary closure of the injury and pressure offloading.